Inspection Reports for Savant of Jurupa Valley
5881 El Palomino Dr, Riverside, CA 92509, United States, CA, 92509
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and the facility consistently met regulatory requirements with no serious issues such as fines or enforcement actions reported. The most recent report dated August 28, 2025, was a complaint investigation that found the allegation of a scabies outbreak notification failure to be unsubstantiated. Throughout the inspection history, multiple complaint investigations were conducted, but nearly all allegations—including those related to resident care, staffing, medication management, and facility conditions—were found unsubstantiated. One isolated deficiency was cited in February 2024 for failure to provide necessary care and supervision, and a medication storage issue was noted in October 2024, but no enforcement or fines resulted. Overall, the facility’s record shows a stable compliance trend with no recent deficiencies and mostly unsubstantiated complaints.
Deficiencies per Year
4
3
2
1
0
High
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 136
Capacity: 197
Deficiencies: 0
Aug 28, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that staff did not notify residents of a scabies outbreak.
Findings
The investigation found that 10 residents reported skin irritations and/or rashes, but the diagnosis was not scabies. The facility took precautions by notifying staff and residents through a newsletter. Based on the information obtained, there was not enough evidence to support the allegation, and it was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff did not notify residents of a scabies outbreak. The allegation was investigated and found to be unsubstantiated.
Report Facts
Residents reporting skin irritations: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during the investigation |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 143
Capacity: 197
Deficiencies: 0
Aug 15, 2025
Visit Reason
The visit was an unannounced required comprehensive annual inspection of the facility.
Findings
The facility was found to be operating within approved capacity and maintained in good condition with no obstructions, adequate furniture, safety equipment, and proper food service. A review of resident and staff files showed compliance with regulations. No deficiencies were cited during this inspection.
Report Facts
Resident files reviewed: 10
Resident medications reviewed: 10
Hospice files reviewed: 1
Staff files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick L. McAdoo-Morton | Administrator/Director | Facility administrator named in the report |
| Javier Prieto | Licensing Program Analyst | Conducted the inspection and signed the report |
| Magda Malcore | Licensing Program Analyst | Accompanied the inspection visit |
| Danielle Garcia | Office Manager/Business Manager | Accompanied the inspection and received the exit interview |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager |
| Pacia | Executive Director | Met with Licensing Program Analysts during inspection |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 197
Deficiencies: 0
Jul 30, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-04-23 regarding staff practices and resident care at the facility.
Findings
The investigation included interviews, record reviews, and observations related to allegations that staff forced residents to stay in bed, forced purchase of insurance, lack of activities, and unmet care needs. All allegations were found to be unsubstantiated based on evidence and interviews.
Complaint Details
The complaint investigation was unsubstantiated for all allegations, including staff making residents stay in bed for extended periods, forcing residents to purchase insurance, not providing activities, and not meeting residents' care needs.
Report Facts
Complaint Control Number: 56-AS-20240423152956
Number of allegations: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renese Howell-Small | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Karen Clemons | Licensing Program Manager | Oversaw the complaint investigation |
| Marc Pacia | Executive Director | Facility representative met during the investigation |
| Patrick L. McAdoo-Morton | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 197
Deficiencies: 0
Jul 29, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations including resident pressure injuries, rough handling by staff, untimely feeding and changing of residents, rodent infestation, facility disrepair, lack of hot water, resident wandering due to lack of supervision, insufficient staffing, and failure of staff to treat residents with dignity and respect.
Findings
Based on observations, record review, and interviews with residents and staff, all allegations were found to be unsubstantiated due to lack of preponderance of evidence. The facility was found to have sufficient staffing, proper maintenance, hot water availability, and no rodent infestation. Residents and staff denied the allegations during interviews.
Complaint Details
The complaint investigation was unsubstantiated. Despite multiple allegations, there was no sufficient evidence to prove violations occurred. The reporting party could not be reached for further information on several allegations.
Report Facts
Capacity: 197
Census: 143
Resident interviews: 6
Staff interviews: 4
Hot water temperature: 105
Hot water temperature: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Magda Malcore | Licensing Program Analyst | Conducted the complaint investigation visit |
| Karen Clemons | Licensing Program Manager | Oversaw the complaint investigation |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 197
Deficiencies: 0
Jul 29, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not ensure a resident was scheduled for doctor's appointments and that staff financially abused a resident in care.
Findings
The investigation found insufficient evidence to support the allegations, and therefore the complaints were deemed unsubstantiated. The Licensing Program Analyst met with the Executive Director and reviewed relevant records including financial documents and staff interviews.
Complaint Details
The complaint investigation was triggered by allegations received on 04/09/2024 regarding failure to schedule doctor's appointments for a resident and financial abuse related to payments made by the resident to the facility. The allegations were found unsubstantiated based on interviews and financial record review.
Report Facts
Complaint Control Number: 56-AS-20240409080322
Facility Capacity: 197
Census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during investigation |
| Patrick L. McAdoo-Morton | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 197
Deficiencies: 0
Jul 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-05-24 regarding aggressive animals on premises, residents being left soiled for long periods, and improper staff training.
Findings
The investigation found that the facility had two small, docile dogs with no signs of aggression, residents denied being left in soiled diapers for long periods, and staff training records showed appropriate mandated in-service training. Therefore, the allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on the findings that the allegations of aggressive animals, residents left soiled, and improper staff training were not supported by evidence.
Report Facts
Capacity: 197
Census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during investigation |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 197
Deficiencies: 0
Jul 29, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-04-08 regarding resident bathing needs, food service adequacy, response to call buttons, and facility odor.
Findings
The investigation included interviews, observations, and record reviews. All allegations were found to be unsubstantiated based on evidence gathered, including resident and staff interviews and facility documentation.
Complaint Details
The complaint investigation was unsubstantiated for all allegations: staff not meeting resident bathing needs, inadequate food service, untimely response to call buttons, and failure to keep the facility free from odor.
Report Facts
Capacity: 197
Census: 144
Number of residents interviewed: 10
Number of staff interviewed: 5
Meals per day: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renese Howell-Small | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Karen Clemons | Licensing Program Manager | Oversaw the complaint investigation |
| Marc Pacia | Executive Director | Facility representative met during the investigation and exit interview |
| Patrick L. McAdoo-Morton | Administrator | Facility administrator listed in the report |
Inspection Report
Census: 143
Capacity: 197
Deficiencies: 0
Jul 28, 2025
Visit Reason
The visit was a Case Management - Other type of inspection involving the signing of amended Complaint Investigation Reports related to two complaints.
Findings
The Licensing Program Analyst arrived to have the Executive Director sign amended Complaint Investigation Reports and the Facility Evaluation Report. The amended reports and evaluation report were signed and copies were left with the facility.
Complaint Details
The visit involved amended Complaint Investigation Reports for complaint #56-AS-20230404134825 and complaint #56-AS-20221222094200.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marc Pacia | Executive Director | Met with during the visit and signed amended Complaint Investigation Reports and Facility Evaluation Report. |
| Javier Prieto | Licensing Program Analyst | Arrived to have Executive Director sign amended Complaint Investigation Reports and Facility Evaluation Report. |
| Patrick L. McAdoo-Morton | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 197
Deficiencies: 0
Jul 28, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 12/22/2022 regarding staff neglect leading to a resident sustaining a pressure injury and staff leaving residents in dirty diapers for extended periods.
Findings
The investigation included interviews with multiple residents and review of care plans and records. No evidence was found to support the allegations, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated based on interviews with residents and review of records, including the service plan of the resident in question who required maximum assistance with toileting and transfers.
Report Facts
Capacity: 197
Census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during the investigation |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 197
Deficiencies: 0
Jul 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-03-06 regarding multiple allegations including unmet resident showering needs, facility disrepair, mold presence, and denial of resident return after hospitalization.
Findings
The investigation found no evidence to substantiate the allegations. Staff interviews and resident interviews indicated showering needs were met. Facility tour revealed no disrepair or mold. The denial of resident return was related to an eviction notice and ongoing unlawful detainer action. Overall, the allegations were unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included unmet showering needs, facility disrepair, mold, and denial of resident return after hospitalization. The facility served an eviction notice to the resident in question, and the resident moved to the hospital. No violations were proven.
Report Facts
Capacity: 197
Census: 144
Complaint control number: 56-AS-20240306083921
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Magda Malcore | Licensing Program Analyst | Conducted the complaint investigation visit |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during the visit |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 197
Deficiencies: 0
Jul 24, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-05-30 regarding resident discharge, medication administration, and call button functionality.
Findings
The investigation found all allegations unsubstantiated after interviews, record reviews, and observations. The facility did not prevent residents from returning after hospital discharge, medications were administered as prescribed, and call buttons were functional.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included the facility not allowing a resident to return after hospital discharge, residents not receiving medications as prescribed, and call buttons not working for months. Interviews and record reviews did not support these allegations.
Report Facts
Number of allegations: 3
Number of staff interviewed: 5
Number of residents interviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renese Howell-Small | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Liz Banuelos | Wellness Director | Met with Licensing Program Analyst during the investigation |
| Patrick L. McAdoo-Morton | Administrator | Facility administrator named in the report |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 197
Deficiencies: 0
Jul 23, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2025-04-16 alleging that staff leave residents soiled for extended periods of time.
Findings
The investigation found the allegation to be unsubstantiated based on interviews with staff and residents, observations, and evidence gathered during the visit. Staff reported checking on residents 3-4 times per shift or more, and residents confirmed they were not left soiled for extended periods.
Complaint Details
The complaint alleged that staff leave residents soiled for extended periods of time. The allegation was found to be unsubstantiated after investigation.
Report Facts
Complaint Control Number: 56-AS-20250416152027
Capacity: 197
Census: 144
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Magda Malcore | Licensing Program Analyst | Conducted the complaint investigation |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 197
Deficiencies: 0
Jul 23, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-01-12 regarding resident care issues including soiled diapers, feeding, and theft.
Findings
The investigation found no evidence to substantiate the allegations. Staff and resident interviews indicated that residents were not left in soiled diapers, were provided meals, and no theft occurred. The complaint was determined to be unsubstantiated.
Complaint Details
The complaint involved allegations that facility staff left residents in soiled diapers, did not ensure residents were fed, and stole from residents. After interviews with staff and residents, the allegations were found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Staff interviews: 4
Resident interviews: 5
Complaint receipt date: Jan 12, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Magda Malcore | Licensing Program Analyst | Conducted the complaint investigation visit |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 197
Deficiencies: 0
Jul 23, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-06-12 regarding staff not ensuring a resident did not have access to knives and staff not reporting the incident to Community Care Licensing or other agencies.
Findings
The investigation found that on 2025-06-05, resident #1 pulled out a pocketknife and verbally threatened resident #2. Staff secured the knife and called law enforcement. An incident report was provided to Community Care Licensing. The allegations were determined to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint involved allegations that staff did not ensure a resident did not have access to knives and did not report the incident to Community Care Licensing or other agencies. The complaint was found to be unsubstantiated.
Report Facts
Complaint Control Number: 56-AS-20250612131659
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Magda Malcore | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during the investigation and received the report |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 197
Deficiencies: 0
Jul 22, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to allegations received on 2024-05-30 regarding staff neglect and inadequate care at the facility.
Findings
The investigation included interviews, record reviews, and observations. All allegations related to staff neglect, hygiene, assistance with transfers, room cleanliness, and meal provision were found to be unsubstantiated based on evidence gathered.
Complaint Details
The complaint included multiple allegations such as staff leaving residents in dirty diapers for extended periods, failure to accommodate residents, failure to keep rooms clean, failure to meet hygiene needs, failure to assist with transfers, and failure to ensure residents ate food. All allegations were investigated and found unsubstantiated.
Report Facts
Staff interviewed: 7
Residents interviewed: 10
Capacity: 197
Census: 144
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renese Howell-Small | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Marc Pacia | Executive Director | Facility representative met during the investigation and exit interview |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 197
Deficiencies: 0
Jul 22, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2022-09-12 regarding inadequate care, unanswered facility phones, and lack of response to resident representative communications.
Findings
The investigation found that most residents and staff reported adequate care was provided, the facility phone system included voicemail and was generally accessible, and communication with resident representatives was maintained in compliance with HIPAA regulations. The allegations were deemed unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with residents and staff, and review of communication procedures. No evidence supported the allegations of inadequate care, unanswered phones, or failure to respond to resident representatives.
Report Facts
Resident interviews conducted: 8
Staff interviews conducted: 4
Resident interviews indicating adequate care: 6
Staff interviews indicating adequate care: 4
Resident interviews indicating no phone issues: 3
Resident interviews indicating no issues with representative communication: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raquel Hernandez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Mark Pacia | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 197
Deficiencies: 0
Jul 22, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not refill a resident's medication prescription in a timely manner causing the resident to be in pain.
Findings
The investigation included interviews with residents and staff and a facility tour. The allegation was found to be unsubstantiated as evidence did not support that the violation occurred. No deficiencies were cited during the visit.
Complaint Details
The complaint was unsubstantiated based on evidence gathered during the investigation. Although the allegation may have been valid, there was not a preponderance of evidence to prove the violation occurred.
Report Facts
Resident interviews conducted: 8
Staff interviews conducted: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raquel Hernandez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Mark Pacia | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 197
Deficiencies: 0
Jun 4, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations of financial abuse of a resident by staff.
Findings
The investigation found no sufficient evidence to substantiate the allegations of financial abuse. Interviews with residents and review of financial records showed no discrepancies or abuse.
Complaint Details
The complaint alleged staff were financially abusing a resident. After interviews with residents and staff and review of payment ledgers, the allegations were deemed unsubstantiated.
Report Facts
Capacity: 197
Census: 146
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during investigation |
| Patrick L. McAdoo-Morton | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 197
Deficiencies: 0
May 14, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff failed to treat residents with dignity and respect and failed to assist residents in a timely manner.
Findings
The investigation included interviews with residents and the Executive Director. All interviewed residents stated that staff treat them with dignity, respect, and assist them in a timely manner. Based on the information obtained, the allegations were deemed unsubstantiated.
Complaint Details
The complaint included allegations that staff failed to treat residents with dignity and respect and failed to assist residents in a timely manner. The complaint was investigated and found to be unsubstantiated.
Report Facts
Capacity: 197
Census: 141
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during the investigation |
| Kenny Espinal | Administrator | Facility administrator named in the report header |
Inspection Report
Census: 151
Capacity: 197
Deficiencies: 0
May 9, 2025
Visit Reason
The visit was a Case Management - Other type of unannounced inspection to have an amended Complaint Investigation Report (LIC 9099) signed.
Findings
The Licensing Program Analyst arrived to the facility to have the amended Complaint Investigation Report signed and left a copy of the report at the facility. No specific deficiencies or findings are detailed in this report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Arrived to the facility to have amended Complaint Investigation Report signed. |
| Patrick L. McAdoo-Morton | Administrator/Director | Named as facility administrator/director. |
| Marca Pacia | Executive Director | Met with Licensing Program Analyst during visit. |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager. |
Inspection Report
Census: 151
Capacity: 197
Deficiencies: 0
May 5, 2025
Visit Reason
Licensing Program Analyst Javier Prieto arrived at the facility to amend complaint 56-AS-20250218090512.
Findings
The report documents the amendment of a prior complaint; no specific deficiencies or findings are detailed in the report.
Complaint Details
The visit was related to amending complaint 56-AS-20250218090512.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Arrived at the facility to amend complaint and signed the report. |
| Marc Pacia | Executive Director | Met during the visit and signed the report. |
| Patrick L. McAdoo-Morton | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 197
Deficiencies: 0
May 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to an allegation that the facility illegally evicted a resident in care.
Findings
The investigation found no evidence that the facility illegally evicted the resident. Interviews with staff and residents confirmed that the resident in question was not evicted and remains at a medical facility awaiting proper placement. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that the facility illegally evicted a resident in care. After investigation, the allegation was found to be unsubstantiated.
Report Facts
Capacity: 197
Census: 151
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 197
Deficiencies: 0
May 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that staff did not safeguard residents' personal belongings and did not ensure residents received incoming mail.
Findings
The investigation found insufficient evidence to support the allegations. Interviews with residents and staff indicated no issues with safeguarding belongings or receiving mail. The allegations were deemed unsubstantiated.
Complaint Details
The complaint involved allegations that staff did not safeguard resident's personal belongings and did not ensure residents received incoming mail. After interviews and review, the complaint was found to be unsubstantiated.
Report Facts
Capacity: 197
Census: 151
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 156
Capacity: 197
Deficiencies: 0
Mar 18, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-03-13 regarding resident safety and supervision concerns.
Findings
The investigation found that the bathroom was equipped with a grab bar as required and there was no evidence that the resident had falls due to lack of a grab bar. The resident reported falling in the shower but did not wait an extended period for assistance. Records and interviews did not support the allegations, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff did not ensure the resident had a shower bar resulting in falls and that due to lack of supervision, the resident was left on the floor for an extended period. The investigation found insufficient evidence to substantiate these claims.
Report Facts
Facility capacity: 197
Resident census: 156
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Audrey Munoz | Wellness Supervisor | Interviewed during the investigation and provided information about the resident and facility |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Patrick L. McAdoo-Morton | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 197
Deficiencies: 0
Mar 6, 2025
Visit Reason
The visit was conducted for case management related to a complaint control number 56-AS-20231206111059 dated 12/08/2023, requiring the Executive Director to address and sign amended documents.
Findings
The report documents the arrival of the Licensing Program Analyst to have the Executive Director address and sign amended complaint-related paperwork. No specific deficiencies or findings are detailed in the report.
Complaint Details
Complaint control number 56-AS-20231206111059 dated 12/08/2023 was the basis for this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Arrived to the facility to have Executive Director address and sign amended complaint documents. |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst to address and sign amended complaint documents. |
| Patrick L. McAdoo-Morton | Administrator/Director | Named as facility administrator/director. |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 159
Capacity: 197
Deficiencies: 0
Mar 6, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-07-08 regarding staff not assisting a resident with wheelchair transfers, not providing three meals, leaving a resident in a soiled diaper, and not safeguarding resident personal belongings.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with residents and review of service plans indicated that the resident's needs were being adequately met, including assistance with toileting, meal delivery, and safeguarding personal belongings. Therefore, the allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with resident #1 and others, review of the Resident Service Plan, and observations. Allegations included failure to assist with wheelchair transfers, failure to provide three meals, leaving a resident in a soiled diaper, and failure to safeguard personal belongings. No evidence supported these claims.
Report Facts
Facility capacity: 197
Census: 159
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during investigation |
| Patrick L. McAdoo-Morton | Administrator | Facility administrator named in the report |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 197
Deficiencies: 0
Feb 28, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that facility staff were not providing medication as prescribed and were not ensuring that residents' oxygen equipment was operable.
Findings
The investigation found insufficient evidence to support the allegations. The Physician's Orders did not include insulin for the resident in question, and the portable oxygen equipment was managed by the resident and/or family. Both allegations were deemed unsubstantiated.
Complaint Details
The complaint alleged that facility staff failed to provide medication as prescribed and did not ensure that residents' oxygen equipment was operable. The allegations were investigated and found to be unsubstantiated.
Report Facts
Facility capacity: 197
Census: 154
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Marc Pacia | Executive Director | Met with the Licensing Program Analyst during the investigation and was involved in the findings |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 197
Deficiencies: 0
Feb 28, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff unlawfully evicted residents while in care.
Findings
The investigation found that proper 30-day eviction notices were issued due to non-payment for care and supervision, and supporting documentation confirmed residents vacated voluntarily or were in the process of eviction. There was insufficient evidence to substantiate the allegation of unlawful eviction.
Complaint Details
The complaint alleging unlawful eviction of residents was investigated and deemed unsubstantiated based on review of eviction documentation and supporting records.
Report Facts
Capacity: 197
Census: 154
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during investigation |
| Danielle Garcia | Business Office Manager | Provided eviction documentation during investigation |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 197
Deficiencies: 0
Feb 26, 2025
Visit Reason
The inspection visit was conducted to further investigate and have the Executive Director sign the amended complaint dated 11/08/2024.
Findings
The report was discussed with the Executive Director and signed by both the Licensing Program Analyst and the Director. A copy of the report was left with the facility.
Complaint Details
The visit was triggered by an amended complaint (56-AS-20241104095010) dated 11/08/2024, which was investigated during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Arrived to the facility to investigate and have the Executive Director sign the amended complaint. |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst and signed the amended complaint. |
| Patrick L. McAdoo-Morton | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 197
Deficiencies: 0
Feb 26, 2025
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that staff were not bathing a resident, not providing food, not responding to calls for assistance, and not taking the resident to the dining room.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with the resident and staff, as well as review of resident care summaries and visual evidence, confirmed that bathing, food provision, call response, and escorting to meals were being appropriately provided.
Complaint Details
The complaint investigation was unsubstantiated based on interviews and evidence. Allegations included failure to bathe resident, provide food, respond to calls, and escort resident to dining room; all were found unsubstantiated.
Report Facts
Capacity: 197
Census: 154
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 197
Deficiencies: 0
Jan 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to multiple allegations received on 2025-01-06 regarding staff performance and resident care at the facility.
Findings
The investigation found that the facility was clean and free from odors, staff assisted residents with hygiene and feeding as required, responded to call buttons, and attended to residents' requests. There was insufficient evidence to substantiate the allegations, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint included allegations that staff did not keep the facility clean or odor-free, did not maintain residents' hygiene, did not feed residents or place meals within reach, did not respond to call buttons, did not assist residents when requested, and left residents in soiled diapers. All allegations were investigated and found unsubstantiated.
Report Facts
Capacity: 197
Census: 158
Number of meals provided: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 197
Deficiencies: 0
Dec 13, 2024
Visit Reason
The visit was conducted to amend documents originally delivered on 07/17/2024 related to a complaint investigation initiated on that date.
Findings
The Licensing Program Analyst arrived to amend the previously delivered documents from the complaint investigation. The amendment was signed by the facility administrator and a copy was provided at the conclusion of the visit.
Complaint Details
Complaint investigation initiated on 07/17/2024 with complaint control number 56-AS-20240715095448. The current visit was to amend the original documents related to this complaint.
Report Facts
Complaint Control Number: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarina Ramirez | Licensing Program Analyst | Arrived at the facility to amend documents related to the complaint investigation |
| Marc Pacia | Administrator | Signed the amendment of the complaint investigation documents |
Inspection Report
Census: 146
Capacity: 197
Deficiencies: 0
Dec 5, 2024
Visit Reason
Licensing Program Analyst Javier Prieto arrived at the facility to have staff resign amended complaint #56-AS-20240916230721.
Findings
The Licensing Program Analyst met with the Administrator, signed the report, and left a copy with the facility. No deficiencies or violations were noted in the report.
Complaint Details
Complaint #56-AS-20240916230721 was the reason for the visit; the report does not state substantiation status.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the visit related to amended complaint and signed the report. |
| Marc Pacia | Administrator | Met with Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 197
Deficiencies: 0
Nov 8, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not respond to call buttons in a timely manner and left a resident on the floor for a prolonged period of time.
Findings
The investigation found insufficient evidence to substantiate the allegations. Residents confirmed call buttons were working and assistance arrived promptly. A reported fall was followed by timely staff response and medical evaluation with no injuries requiring attention. The allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included delayed response to call buttons and leaving a resident on the floor for a prolonged period. Interviews with residents and review of records did not support these claims.
Report Facts
Capacity: 197
Census: 146
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Marc Pacia | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Patrick L. McAdoo-Morton | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 197
Deficiencies: 0
Oct 30, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff did not prevent a resident from sexually abusing another resident.
Findings
The investigation found insufficient evidence to substantiate the allegation. Interviews with residents and the Executive Director did not corroborate the claim, and an internal investigation was conducted with no supporting findings.
Complaint Details
The allegation that staff did not prevent a resident from sexually abusing another resident was investigated and deemed unsubstantiated based on interviews and internal investigation.
Report Facts
Capacity: 197
Census: 147
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Marc Pacia | Executive Director | Met with investigator and conducted internal investigation |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 197
Deficiencies: 0
Oct 24, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that facility staff were not properly addressing pest infestation in the facility.
Findings
The investigation found that the facility properly addresses pest infestation through monthly treatment services and spot treatments, supported by invoices and resident interviews. Therefore, the allegations were deemed unsubstantiated.
Complaint Details
The complaint alleged that facility staff were not properly addressing pest infestation. The investigation found sufficient evidence of pest control measures including monthly treatments and spot treatments, leading to the complaint being unsubstantiated.
Report Facts
Capacity: 197
Census: 148
Days since last pest treatment: 13
Days since last rodent treatment: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Danielle Garcia | Business Director | Met with Licensing Program Analyst during investigation |
| Patrick L. McAdoo-Morton | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 197
Deficiencies: 0
Oct 24, 2024
Visit Reason
The inspection was an unannounced complaint investigation regarding an allegation that staff stole a resident's money.
Findings
The investigation found that the allegation was unfounded; documentation showed the resident was approved for the Assisted Living Waiver program with no stipend due, and no funds were dispensed through the Business Manager.
Complaint Details
The complaint alleged that staff stole resident #1's money related to a stipend of $177 due after rent payment under the Assisted Living Waiver program. The complaint was found to be unfounded and dismissed.
Report Facts
Capacity: 197
Census: 148
Stipend amount: 177
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Danielle Garcia | Business Manager | Met with investigator and provided documentation related to the complaint |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 197
Deficiencies: 0
Oct 24, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-03-25 regarding staff moving a resident without consent and inappropriate staff communication.
Findings
The investigation found insufficient evidence to substantiate the allegations that staff moved the resident without consent or spoke inappropriately to the resident. The resident was moved per family request and was aware of the move, and the resident was satisfied with care and accommodations.
Complaint Details
The complaint involved allegations that staff moved a resident to another room without her consent and spoke inappropriately to the resident. The allegations were deemed unsubstantiated based on interviews and review of the resident's needs and services plan.
Report Facts
Facility capacity: 197
Census: 148
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 197
Deficiencies: 0
Oct 23, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding allegations of unlawful eviction at the facility.
Findings
The investigation found that the eviction documentation for the resident was legal and properly filed with the Superior Court. The complaint of unlawful eviction was determined to be unfounded and was dismissed.
Complaint Details
The complaint alleged unlawful eviction. The investigation found the complaint to be unfounded, meaning the allegations were false or without reasonable basis.
Report Facts
Non-payment amount: 18669.45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Danielle Garcia | Business Manager | Met with the Licensing Program Analyst during the investigation |
| Patrick L. McAdoo-Morton | Administrator | Named as facility administrator |
| Karen Clemons | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 155
Capacity: 197
Deficiencies: 1
Oct 9, 2024
Visit Reason
The visit was an unannounced required comprehensive annual inspection to evaluate the facility's compliance with licensing regulations.
Findings
The facility was generally compliant with regulations regarding physical plant, food service, and care supervision. However, a Type A deficiency was cited due to medication carts containing loose pills, posing an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medication carts had loose pills; 3 out of 4 carts contained loose pills, with 7 loose pills observed, violating medication storage requirements. | Type A |
Report Facts
Resident files reviewed: 15
Resident medications reviewed: 15
Hospice files reviewed: 3
Resident safeguard audit: 10
Staff files reviewed: 10
Loose pills observed: 7
Medication carts with loose pills: 3
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Rico | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Patrick L. Mcadoo-Morton | Regional Manager | Accompanied the Licensing Program Analyst during inspection and involved in exit interview |
| Marc Pacia | Administrator | Accompanied the Licensing Program Analyst during inspection and involved in exit interview |
Inspection Report
Complaint Investigation
Census: 157
Capacity: 197
Deficiencies: 0
Oct 8, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to an allegation that staff do not ensure the facility is free from bed bugs.
Findings
The investigation found insufficient evidence to substantiate the allegation of bed bugs. Interviews with residents and facility staff, along with exterminator records, indicated the issue was resolved and the facility routinely treats for pests.
Complaint Details
The complaint was unsubstantiated based on interviews with residents and staff, and review of exterminator treatment records. The allegation that staff failed to ensure the facility was free from bed bugs was not supported by the evidence.
Report Facts
Facility capacity: 197
Resident census: 157
Complaint received date: Sep 30, 2024
Complaint control number: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during investigation and provided information |
| Tiffany | Maintenance Director | Provided information about pest treatment and resident room status |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 197
Deficiencies: 0
Oct 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that staff removed residents’ personal belongings without consent and that the licensee does not ensure sufficient staffing to meet residents’ care needs.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Interviews with residents and staff, as well as facility roster review, indicated that personal belongings were not removed without consent and staffing levels were sufficient to meet residents' needs.
Complaint Details
The complaint was unsubstantiated based on interviews with residents and staff and review of facility staffing. Allegations included unauthorized removal of personal belongings and insufficient staffing, both of which were found unsubstantiated.
Report Facts
Capacity: 197
Census: 155
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 197
Deficiencies: 0
Sep 19, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that staff used a resident's bathroom and failed to prevent a resident from smoking in their room.
Findings
The investigation found insufficient evidence to support the allegations. Staff confirmed they do not use residents' bathrooms, and the resident denied smoking in their room. The facility's no-smoking policy is clearly posted and included in admissions agreements. The allegations were deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated based on interviews with staff and a resident, review of facility policies, and observation. Allegations included staff using a resident's bathroom and failure to prevent smoking in a resident's room.
Report Facts
Capacity: 197
Census: 155
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Danielle Garcia | Office Manager | Met with Licensing Program Analyst during investigation |
| Patrick L. McAdoo-Morton | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 197
Deficiencies: 0
Sep 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation regarding an allegation that staff did not ensure the facility was free of pests.
Findings
The investigation found that the facility was providing preventative measures to address pest issues, including weekly and monthly treatments by pest control companies and extra cleaning. The allegation was deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that staff did not ensure the facility was free of pests. The allegation was unsubstantiated after interviews and observations, including confirmation of pest control services and preventative measures.
Report Facts
Capacity: 197
Census: 158
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick L. McAdoo-Morton | Regional Director | Met with Licensing Program Analysts during the complaint investigation |
| Danielle Garcia | Business Manager | Provided documentation related to pest control measures |
| Lavette Farlow | Licensing Program Analyst | Conducted the complaint investigation |
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 197
Deficiencies: 0
Aug 9, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-02-27 regarding staff safeguarding resident belongings, confiscation of resident vitamins, and ensuring resident transportation to medical appointments.
Findings
The investigation found no evidence to substantiate the allegations. Interviews with residents and staff, as well as record reviews, indicated that staff are safeguarding residents' belongings, vitamins are only confiscated when not authorized by a doctor's order, and residents are transported to medical appointments as required.
Complaint Details
The complaint involved three allegations: 1) Staff are not safeguarding resident's personal belongings, 2) Staff confiscated resident's vitamins, and 3) Facility did not ensure that resident was transported to a medical appointment. All allegations were found to be unsubstantiated based on interviews and record reviews.
Report Facts
Residents interviewed: 13
Staff interviewed: 5
Facility capacity: 197
Census: 158
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melody Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Maryann Nevarez | Executive Director | Met with Licensing Program Analysts during the visit |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
| Patrick L. McAdoo-Morton | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 197
Deficiencies: 0
Aug 6, 2024
Visit Reason
The inspection was an unannounced complaint investigation regarding an allegation that staff were not providing medication to a resident in care.
Findings
The investigation found that medication was administered as prescribed according to the Medication Administration Records and interviews, and there was not enough evidence to substantiate the allegation. The complaint was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff were not providing medication to a resident. The allegation was investigated and found to be unsubstantiated based on medication records and resident interview.
Report Facts
Capacity: 197
Census: 158
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Maria Nevarez | Executive Director | Met with Licensing Program Analyst during investigation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 197
Deficiencies: 0
Jul 30, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff did not ensure the admissions agreement was being followed and that personal funds were not disbursed to residents in a timely manner.
Findings
The investigation found that the facility was following the terms of the admissions agreement regarding visitation hours and that personal funds were being dispensed appropriately. Therefore, the allegations were deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated based on interviews and documentation reviewed, including admissions agreements and personal funds records for resident #1.
Report Facts
Capacity: 197
Census: 158
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Patrick L. McAdoo-Morton | Administrator | Facility administrator named in the report header |
| Danielle Garcia | Business Manager | Met with investigators and provided documentation related to the complaint |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 197
Deficiencies: 0
Jul 30, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff were interfering with resident visits.
Findings
The investigation found insufficient evidence to substantiate the allegation that staff interfered with resident visits. The visiting person was restricted due to a law enforcement limitation order, which staff were enforcing.
Complaint Details
The complaint was unsubstantiated based on interviews with residents and review of the situation involving a law enforcement limitation order.
Report Facts
Capacity: 197
Census: 158
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 197
Deficiencies: 0
Jul 17, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff left a resident soiled for an extended period of time.
Findings
The investigation included interviews with staff, residents, and review of documentation. One resident stated they were left in soiled diapers for an extended period, two residents said they were sometimes left wet, and three residents stated they were not left in soiled diapers. There was insufficient evidence to corroborate the allegation, and it was determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff left a resident soiled for an extended period of time. The allegation was found to be unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 197
Census: 155
Resident interviews conducted: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick L. Mcadoo-Morton | Executive Director | Met with Licensing Program Analysts during the complaint investigation |
| Sarina Ramirez | Licensing Program Analyst | Conducted the complaint investigation |
| Javier Prieto | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Karen Clemons | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 197
Deficiencies: 0
Jun 24, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation regarding an allegation that staff did not fix the running water timely.
Findings
The investigation found no evidence to corroborate the allegation. Interviews with residents and staff indicated the running water issue was addressed timely, and the facility provided water to residents during the outage. The complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff did not fix the running water timely. The complaint was unsubstantiated based on interviews and documentation reviewed during the investigation.
Report Facts
Residents interviewed: 8
Staff interviewed: 5
Facility capacity: 197
Census: 155
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick L. McAdoo-Morton | Executive Director | Met with Licensing Program Analyst and named in investigation findings |
| Melody Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 197
Deficiencies: 0
Jun 21, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff did not ensure the facility was free of mold, odor, and rodents.
Findings
The Licensing Program Analyst toured the facility and did not observe mold, foul odors, or rodents. The Executive Director provided pest control documentation indicating no rodent activity. Based on the investigation, the allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on lack of evidence supporting the allegations of mold, odor, and rodent presence.
Report Facts
Complaint Control Number: 56
Complaint Control Number Suffix: 20240619151040
Capacity: 197
Census: 154
Pest Control Visit Date: May 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Patrick L. McAdoo-Morton | Executive Director | Met with Licensing Program Analyst during investigation and provided pest control documentation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 197
Deficiencies: 0
Jun 19, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff were not assisting residents in a timely manner and not ensuring residents were provided adequate food service.
Findings
The investigation found that communication with staff was timely and that residents received adequate food service. Resident and staff interviews indicated no evidence supporting the allegations. Therefore, the complaints were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with resident #1 and staff #1, who confirmed timely assistance and adequate food service. The resident reported that meals refused were by personal choice and praised the meal quality and social environment.
Report Facts
Capacity: 197
Census: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick L. McAdoo-Morton | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 161
Capacity: 197
Deficiencies: 0
May 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff did not answer residents' calls for assistance timely and that staff contacted social security without residents' permission.
Findings
The investigation found insufficient evidence to substantiate the allegation that staff did not answer residents' calls timely, deeming it unsubstantiated. The allegation that staff contacted social security without residents' permission was found to be unfounded based on documentation authorizing the facility to handle residents' social security deposits.
Complaint Details
The complaint investigation addressed two allegations: 1) staff did not answer residents calls for assistance timely, which was unsubstantiated due to lack of evidence; 2) staff contacted social security without residents' permission, which was unfounded based on a signed authorization document allowing the facility access to residents' social security and Supplemental Security Income.
Report Facts
Capacity: 197
Census: 161
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick L. McAdoo-Morton | Executive Director | Met with Licensing Program Analyst during complaint investigation and provided information regarding allegations |
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 161
Capacity: 197
Deficiencies: 0
May 9, 2024
Visit Reason
The visit was a case management inspection related to an incident that occurred on 2024-05-07 involving resident #1 and an altercation with two staff members and a witness staff member.
Findings
The Licensing Program Analyst conducted interviews including with the Executive Director and attempted to interview the resident involved, who did not comply. The report documents the incident and the interviews conducted.
Complaint Details
The visit was triggered by a complaint or incident involving resident #1 and staff members S1, S2, and S3. Resident #1 refused to comply with the interview. No substantiation status is stated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick L. McAdoo-Morton | Executive Director | Interviewed regarding the incident involving resident #1. |
| Javier Prieto | Licensing Program Analyst | Conducted the case management visit and interviews. |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 197
Deficiencies: 0
Apr 29, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff opened a resident's luggage without permission, changed the resident's doctor without permission, and spoke inappropriately to the resident.
Findings
The investigation found insufficient evidence to substantiate the allegations. The resident confirmed the luggage was opened in their presence to retrieve medication, the resident still had the same doctor, and the alleged inappropriate speech was described as a 'heated moment.' Therefore, all allegations were deemed unsubstantiated.
Complaint Details
The complaint involved three allegations: staff opening resident's luggage without permission, changing the resident's doctor without permission, and speaking inappropriately to the resident. The investigation concluded these allegations were unsubstantiated.
Report Facts
Facility capacity: 197
Census: 158
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Danielle Garcia | Officer Manager | Met with Licensing Program Analyst during investigation |
| Patrick L. McAdoo-Morton | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 197
Deficiencies: 0
Apr 29, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2024-02-07 regarding the facility charging higher amounts than state standards allow for SSI, improper rent increases, and denial of residents' authorized representatives at facility meetings.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Documentation showed proper rent increase notifications were given, rent increases aligned with social security benefit increases, and residents' authorized representatives were not denied access to facility meetings. Evictions were due to non-payment, not rate increases.
Complaint Details
The complaint was unsubstantiated based on the investigation findings. Allegations included charging higher amounts than allowed for SSI, improper rent increase procedures, and denial of authorized representatives at meetings. Interviews and documentation supported that the facility complied with regulations.
Report Facts
Capacity: 197
Census: 158
Complaint control number: 56-AS-20240207084938
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Patrick L. McAdoo-Morton | Administrator / Executive Director | Interviewed regarding eviction notices and rent increase procedures |
| Danielle Garcia | Office Manager / Business Office Manager | Interviewed regarding complaint allegations and signed the report |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 197
Deficiencies: 0
Apr 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that staff did not ensure transportation was available for a resident and that staff threatened to evict a resident.
Findings
The investigation found that transportation issues had been rectified with an alternate means necessary during early morning hours, and that rent was paid on time with no eviction threat. Therefore, the allegations were deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint involved allegations that staff did not ensure transportation for a resident and threatened eviction. The allegations were investigated and found unsubstantiated.
Report Facts
Capacity: 197
Census: 158
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
| Patrick L. McAdoo-Morton | Administrator | Facility administrator mentioned in report header |
| Danielle Garcia | Officer Manager | Met with Licensing Program Analyst during investigation and confirmed rent status |
Inspection Report
Complaint Investigation
Census: 156
Capacity: 197
Deficiencies: 0
Apr 8, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident was left soiled for an extended period while in care and that staff were not meeting the resident's hygiene needs.
Findings
The investigation found insufficient evidence to substantiate the allegations. The resident's service plan indicated appropriate bathing and toileting assistance, and staff had assisted the resident in obtaining incontinence care products. The allegations were deemed unsubstantiated.
Complaint Details
The complaint involved allegations that a resident was left soiled for an extended period and that staff were not meeting the resident's hygiene needs. After investigation, these allegations were found to be unsubstantiated.
Report Facts
Capacity: 197
Census: 156
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Patrick L. McAdoo-Morton | Administrator | Facility administrator named in the report |
| Savanna Castro | Assistant Business Office Manager | Met with the Licensing Program Analyst during the investigation |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 156
Capacity: 197
Deficiencies: 0
Mar 1, 2024
Visit Reason
The visit was an unannounced case management visit to assess facility compliance, address complaints from residents, and investigate a specific incident related to the passing of resident #1 on February 28, 2024.
Findings
The facility was found to be clean and in order with no deficiencies observed. Resident concerns were addressed appropriately and timely, and no deficiencies were cited during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick L. McAdoo-Morton | Executive Director | Met with Licensing Program Analyst during the visit and involved in addressing resident complaints. |
| Javier Prieto | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 153
Capacity: 197
Deficiencies: 0
Feb 27, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-01-24 regarding medication errors, pressure injuries, and feeding concerns at the facility.
Findings
The investigation found all allegations unsubstantiated after reviewing medication records, interviewing staff and residents, and conducting a facility walkthrough. No medications were missing or incorrectly administered, and no resident was left in urine or feces.
Complaint Details
The complaint included allegations that staff dispensed medications not prescribed, dispensed medication to which a resident was allergic, a resident sustained a pressure injury, and a resident was not fed while in care. All allegations were found unsubstantiated.
Report Facts
Facility capacity: 197
Census: 153
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick L. McAdoo-Morton | Executive Director | Met with Licensing Program Analyst during the investigation |
| Amber Coleman | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 153
Capacity: 197
Deficiencies: 1
Feb 27, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff left a resident in urine and feces.
Findings
Based on interviews with staff and residents, the allegation that staff left a resident in urine and feces was found to be unsubstantiated. However, a deficiency was cited regarding the administrator's failure to provide necessary care and supervision to meet residents' needs.
Complaint Details
The complaint alleged that staff left a resident in urine and feces. The investigation found this allegation unsubstantiated after interviews with residents and staff. Resident #1, the subject of the allegation, had vacated the facility prior to the investigation and was unavailable for interview.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide necessary care and supervision to meet the client's needs, as residents and third party staff reported requesting assistance on numerous occasions and receiving no response. | Type A |
Report Facts
Capacity: 197
Census: 153
Deficiency Type A: 1
Plan of Correction Due Date: Due date for plan of correction is 02/28/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick L. McAdoo-Morton | Executive Director | Met with Licensing Program Analyst and named in findings regarding care and supervision |
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Amber Coleman | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
| Nedra Brown | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 197
Deficiencies: 0
Feb 20, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that the facility did not ensure resident hygiene needs were met and did not follow a resident's modified food diet.
Findings
The investigation found insufficient evidence to substantiate the allegations. Resident #1 was offered bathing services and additional family support, and the vegetarian diet preference was accommodated with additional meals. Therefore, the allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on interviews and documentation reviewed regarding resident hygiene and modified diet adherence.
Report Facts
Facility capacity: 197
Resident census: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Patrick L. McAdoo-Morton | Executive Director | Met with Licensing Program Analyst during the investigation |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 197
Deficiencies: 0
Jan 29, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff left a resident in a soiled diaper for an extended period of time.
Findings
The investigation included staff interviews, resident interviews, document reviews, and a facility tour. All residents and staff denied the allegation, and the facility demonstrated upgraded call systems to assist residents. The allegation was deemed unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleged that staff left a resident in a soiled diaper for an extended period. The allegation was found to be unsubstantiated based on interviews and observations.
Report Facts
Capacity: 197
Census: 148
Number of caregivers per shift: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick L. Mcadoo-Morton | Administrator | Met with Licensing Program Analyst and involved in investigation |
| Mary Rico | Licensing Program Analyst | Conducted the complaint investigation |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 197
Deficiencies: 0
Jan 17, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2024-01-10 regarding staff harassing a resident over monthly payments and staff disclosing residents' personal information in the presence of other residents.
Findings
The investigation found insufficient evidence to substantiate the allegations of staff harassment related to monthly payments and disclosure of residents' personal information. The resident acknowledged the need for privacy and agreed that discussions were afforded in relation to privacy. Therefore, the allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on interviews and documentation. The allegations included staff harassing a resident over monthly payments and disclosing personal information in the presence of other residents. The resident was on a monthly payment plan with monies in arrears, and discussions about payments were necessary. The resident did not want discussions to be private but understood the need for privacy. No evidence supported the allegations.
Report Facts
Facility Capacity: 197
Census: 144
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Patrick L. McAdoo-Morton | Executive Director | Met with Licensing Program Analyst during investigation and signed the report |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 197
Deficiencies: 0
Dec 8, 2023
Visit Reason
The inspection was an unannounced complaint investigation initiated due to allegations that staff were not giving medication to a resident as prescribed and not assisting residents in a timely manner.
Findings
The investigation found that medications were being dispensed as prescribed and residents were receiving assistance in a timely manner. Interviews with residents and staff supported that the allegations were unsubstantiated.
Complaint Details
The complaint involved allegations that staff were not giving medication to a resident as prescribed and not assisting residents in a timely manner. The investigation concluded these allegations were unsubstantiated based on interviews and record reviews.
Report Facts
Capacity: 197
Census: 142
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Patrick L. McAdoo-Morton | Administrator | Facility administrator involved in the investigation |
| Marc Pacia | Executive Director | Met with Licensing Program Analyst during investigation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 143
Capacity: 197
Deficiencies: 0
Nov 28, 2023
Visit Reason
An unannounced case management visit was conducted pertaining to the old facility Villa De Anza Assisted Living regarding four complaints.
Findings
The Licensing Program Analyst conducted the visit and discussed the report with the Executive Director during an exit interview.
Complaint Details
The visit was related to four complaints identified by their complaint numbers: 18-AS-20210719133022, 18-AS-20210609144620, 18-AS-20210716151500, and 18-AS-20210706142605.
Report Facts
Complaints referenced: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick McAdoo-Morton | Executive Director | Met with during the inspection and exit interview |
| Mary Rico | Licensing Program Analyst | Conducted the unannounced case management visit |
| Efren Malagon | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 197
Deficiencies: 0
Nov 20, 2023
Visit Reason
Unannounced collateral visit on a complaint investigation to interview residents regarding complaint control numbers 18-AS-20210601164527.
Findings
The Licensing Program Analyst conducted interviews with residents as part of the complaint investigation and held an exit interview with the Executive Director. A copy of the report was provided to the Executive Director.
Complaint Details
Complaint investigation related to complaint control numbers 18-AS-20210601164527 and 18-AS-20210601164527. No substantiation status stated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick McAdoo-Morton | Executive Director | Met with Licensing Program Analyst during complaint investigation visit. |
| Melody Brown | Licensing Program Analyst | Conducted the complaint investigation visit and interviews. |
| Efren Malagon | Licensing Program Manager | Named in the report header. |
Inspection Report
Census: 138
Capacity: 197
Deficiencies: 0
Nov 1, 2023
Visit Reason
An unannounced case management visit was conducted pertaining to four complaints related to the old facility Villa De Anza Assisted Living 331800471.
Findings
During the visit, the Licensing Program Analyst received facility documents, toured the facility, and confirmed that resident R1 does not reside at the facility. An exit interview was conducted and the report was discussed with Sofia Moreno.
Complaint Details
The visit was related to four complaints identified by their complaint numbers: 18-AS-20210719133022, 18-AS-20210609144620, 18-AS-20210716151500, and 18-AS-20210706142605.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Rico | Licensing Program Analyst | Conducted the unannounced case management visit and received facility documents. |
| Efren Malagon | Licensing Program Manager | Named as Licensing Program Manager in the report. |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 197
Deficiencies: 0
Oct 18, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-10-11 regarding allegations that staff did not meet resident's medical needs, did not assist residents in a timely manner, and that the facility was in disrepair.
Findings
The investigation included a facility tour, resident and staff interviews, and document review. The allegations were found to be unsubstantiated due to insufficient evidence to prove the alleged violations occurred.
Complaint Details
The complaint involved three allegations: staff not meeting resident's medical needs, staff not assisting residents timely, and facility disrepair. The investigation found no evidence to substantiate these claims, noting that the facility is not required to provide a bed with full rails without a doctor's order, call pendents were functioning properly, and the alleged fire did not occur with smoke detectors working as expected.
Report Facts
Capacity: 197
Census: 140
Number of allegations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Patrick McAdoo-Morton | Executive Director | Met with Licensing Program Analyst during investigation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 140
Capacity: 197
Deficiencies: 0
Oct 18, 2023
Visit Reason
The visit was an unannounced required comprehensive annual inspection of the Residential Care Facility for Elderly (RCFE).
Findings
The facility was found to be operating within approved capacity, clean, in good repair, and safe for clients. No deficiencies were cited during the inspection.
Report Facts
Resident files reviewed: 20
Staff files reviewed: 4
Water temperature: 116.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick McAdoo-Morton | Executive Director | Met with Licensing Program Analyst during inspection and received the report. |
| Javier Prieto | Licensing Program Analyst | Conducted the unannounced annual inspection visit. |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 138
Capacity: 197
Deficiencies: 0
Oct 3, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff neglected a resident resulting in a pressure injury and left a resident unattended with dry feces.
Findings
The investigation found insufficient evidence to substantiate the allegations. Records and interviews indicated the resident was attended to regularly, did not have a pressure injury, and was not left unattended with dry feces. The allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on the evidence obtained. Allegations included staff neglect causing a pressure injury and leaving a resident unattended with dry feces, both of which were not supported by the investigation findings.
Report Facts
Capacity: 197
Census: 138
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Patrick McAdoo-Morton | Administrator | Met with the Licensing Program Analyst during the investigation |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 197
Deficiencies: 0
Jul 20, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that facility staff did not ensure that a resident had a means of calling for assistance.
Findings
The investigation found that resident #1 had a call pendent on her person and was able to use it for assistance. There was not enough evidence to substantiate the allegation, and it was deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated based on interviews, observations, and record reviews. The allegation that facility staff did not ensure that a resident had a means of calling for assistance was not supported by evidence.
Report Facts
Capacity: 197
Census: 116
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Patrick McAdoo Morton | Executive Director | Met with Licensing Program Analyst during investigation and provided information about resident call pendent |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 197
Deficiencies: 0
Jul 12, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding multiple allegations including questionable death, resident fracture, lack of supervision, inadequate food service, unsafe environment, insufficient staffing, and facility disrepair.
Findings
The investigation found no evidence to substantiate any of the allegations. Resident #1 had a documented fall but no fracture or neglect was found. Other allegations such as inappropriate resident interactions, inadequate assistance, insufficient staffing, and facility disrepair were also unsubstantiated. The complaint was deemed unfounded and dismissed.
Complaint Details
The complaint included allegations of questionable death, resident sustaining a fracture, lack of supervision leading to inappropriate interactions, failure to assist residents timely, insufficient staffing, unattended residents in soiled diapers, inadequate food service, unsafe environment, failure to perform safety inspections, uncomfortable temperatures, and facility disrepair. All allegations were investigated and found unsubstantiated or unfounded.
Report Facts
Capacity: 197
Census: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Patrick McAdoo-Morton | Executive Director | Met with Licensing Program Analyst during investigation |
| Karen Clemons | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 197
Deficiencies: 0
Jun 20, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that the facility had pests.
Findings
The investigation found no evidence of pests in the facility based on interviews with residents and staff, document review, and a facility tour. The allegation was determined to be unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleged the facility had pests. The allegation was unsubstantiated after investigation, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 197
Census: 115
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Rico | Licensing Program Analyst | Conducted the complaint investigation visit |
| Patrick Mcdoo-Morton | Facility Administrator met during the investigation | |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 197
Deficiencies: 0
Jun 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding an allegation that the facility unlawfully evicted a resident.
Findings
The investigation found insufficient evidence to support the allegation that the facility unlawfully evicted the resident. The resident was confirmed to be hospitalized since transfer on 2023-06-07, and the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that the facility unlawfully evicted a resident. The allegation was investigated and found to be unsubstantiated.
Report Facts
Capacity: 197
Census: 113
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Patrick McAdoo Morton | Executive Director | Met with the investigator and provided information regarding the complaint |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 197
Deficiencies: 0
May 26, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations received on 2023-05-24 regarding medication administration, facility disrepair, insects, food portions, sanitation, incontinence supplies, bedding, and odors.
Findings
The investigation found that medications were administered as prescribed, the facility was in good repair and free of insects, food portions were adequate, the facility was clean and odor-free, and incontinence supplies and bedding were the responsibility of residents or their responsible parties. Overall, there was insufficient evidence to substantiate the allegations, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on the findings that medication administration was proper, the facility was well maintained and clean, food portions were adequate, and supplies such as incontinence products and bedding were the responsibility of residents or their responsible parties.
Report Facts
Capacity: 197
Census: 106
Number of residents' MAR logs reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Patrick McAdoo Morton | Administrator | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 197
Deficiencies: 0
May 26, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-04-04 regarding neglect, inadequate care, and food service failures at the facility.
Findings
The investigation found insufficient evidence to substantiate the allegations of neglect, unattended residents in dirty diapers, inadequate food service, and failure to assist residents. The call button system was tested and found to be in working order, and resident interviews indicated staff responded to care needs.
Complaint Details
The complaint included allegations of resident neglect, staff leaving residents unattended in dirty diapers, failure to provide adequate food service, and failure to assist residents in care. The investigation concluded these allegations were unsubstantiated.
Report Facts
Facility capacity: 197
Census: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Patrick McAdoo Morton | Administrator | Met with investigator during complaint investigation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 104
Capacity: 197
Deficiencies: 0
May 4, 2023
Visit Reason
The visit was an unannounced case management visit to ensure that staff member Victoria Renee Mainor is no longer working at the facility, based on a Decision and Order of exclusion.
Findings
The Licensing Program Analyst confirmed with the Executive Director that Victoria Renee Mainor is excluded from working or being present at the facility and has agreed that Mainor cannot have contact with residents. Records showed Mainor was last present and employed at the facility on 04/14/2023.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Renee Mainor | Staff member excluded from working at the facility. | |
| Partrick Lee McAdoo-Morton | Executive Director | Met during the visit and acknowledged the exclusion of Victoria Renee Mainor. |
| Javier Prieto | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Census: 104
Capacity: 197
Deficiencies: 0
May 4, 2023
Visit Reason
A Health and Safety visit was conducted as a Case Management - Other type of visit. The Licensing Program Analyst met with the recently appointed Executive Director and toured the facility.
Findings
The facility appeared clean and sanitized with no observed concerns regarding the health and safety of the residents. Upgrades were noted in the dining and common areas, and the facility was newly decorated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Lee McAdoo-Morton | Executive Director | Met with Licensing Program Analyst during the visit |
| Javier Prieto | Licensing Program Analyst | Conducted the Health and Safety visit |
| Karen Clemons | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 197
Deficiencies: 0
Feb 22, 2023
Visit Reason
The visit was an unannounced complaint investigation to determine the validity of an allegation that a resident was being illegally evicted from the facility.
Findings
The investigation found that the resident was substantially in arrears with rent and fees, had been properly served eviction notice, and was aware of the situation. The resident no longer wished to reside at the facility and had obtained outside assistance for relocation. The complaint was determined to be unfounded and dismissed.
Complaint Details
The complaint alleged that a resident was being illegally evicted. The complaint was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis.
Report Facts
Capacity: 197
Census: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Katherine Trevino | Executive Director | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 197
Deficiencies: 0
Feb 16, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-11-01 regarding improper notice of rate increase and failure to assist with transportation arrangements.
Findings
The investigation found insufficient evidence to substantiate the allegations. The facility provided assistance with transportation arrangements and gave proper notice of the rate increase, although the resident was unsure if the notice letter was received.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to provide proper notice of rate increase and failure to assist with transportation arrangements. Interviews and evidence showed the facility did provide assistance and notice as required.
Report Facts
Facility capacity: 197
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Katherine Trevino | Executive Director | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 197
Deficiencies: 0
Feb 15, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2022-09-13 regarding resident care concerns including showering, laundry, medication administration, and privacy.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff were found to be meeting the resident's showering, laundry, and medication needs as prescribed, and respecting privacy protocols. Therefore, the allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on documentation, staff interviews, and resident admission records. The resident refused some services as a personal right, and staff followed proper procedures.
Report Facts
Facility capacity: 197
Resident census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Katherine Trevino | Director | Met with investigator during complaint investigation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 197
Deficiencies: 0
Feb 14, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff were financially abusing a resident and not according resident privacy.
Findings
The investigation found insufficient evidence to substantiate the allegations of financial abuse and lack of privacy by staff. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint was unsubstantiated based on interviews and investigation findings; the resident denied knowledge of financial abuse and acknowledged staff entering rooms for cleaning while residents were not present.
Report Facts
Capacity: 197
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Katherine Trevino | Director | Met with investigators during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 197
Deficiencies: 0
Feb 13, 2023
Visit Reason
Unannounced collateral visit on a complaint investigation to obtain Resident #1 facility records in reference to complaint control number 18-AS-20211223155629.
Findings
Licensing Program Analyst Melody Brown conducted the visit and met with Executive Director Katherine Trevino. An exit interview was conducted and a copy of the report was provided to the Executive Director.
Complaint Details
Visit was related to complaint control number 18-AS-20211223155629; no substantiation status stated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melody Brown | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Katherine Trevino | Executive Director | Met with Licensing Program Analyst during the visit. |
| Efren Malagon | Licensing Program Manager | Named in report header. |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 197
Deficiencies: 0
Jan 30, 2023
Visit Reason
The inspection was an unannounced complaint investigation regarding allegations that staff do not safeguard residents' personal items.
Findings
The investigation found the complaint to be unfounded after interviewing the resident and facility staff, concluding that the allegations were false and without reasonable basis.
Complaint Details
The complaint alleged that staff failed to safeguard a resident's personal items. The resident denied the allegations, stating that the items were not mishandled by facility staff. The complaint was determined to be unfounded.
Report Facts
Capacity: 197
Census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Katherine Trevino | Executive Director | Met with Licensing Program Analyst during investigation |
| Karen Clemons | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 197
Deficiencies: 0
Jan 26, 2023
Visit Reason
The visit was an unannounced collateral visit on a complaint investigation to interview residents and staff regarding multiple complaint control numbers.
Findings
The Licensing Program Analyst conducted interviews and met with the facility Culinary Director. An exit interview was conducted and a copy of the report was provided to the Culinary Director.
Complaint Details
The visit was related to complaint control numbers 18-AS-20211105113658, 18-AS-20211213104627, and 18-AS-20211216163843.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bill Heiderscheit | Culinary Director | Met during the complaint investigation visit and received the exit interview and report. |
| Melody Brown | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Efren Malagon | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 197
Deficiencies: 0
Sep 23, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations of financial abuse of a resident while in care.
Findings
The investigation found no evidence of the alleged financial abuse; no resident matching the allegation was found to reside at the facility. The complaint was determined to be unfounded and dismissed. No deficiencies were cited during the visit.
Complaint Details
The complaint alleged that from June 30, 2022 to August 17, 2022, a resident was being financially abused while in care. The complaint was investigated and found to be unfounded.
Report Facts
Capacity: 197
Census: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rayshaun Nickolas | Licensing Program Analyst | Conducted the complaint investigation visit |
| Katherine Trevino | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Census: 91
Capacity: 197
Deficiencies: 1
Sep 9, 2022
Visit Reason
Licensing Program Analyst Ryan Gardner made an unannounced visit to conduct a Health and Safety check of the clients in care at the facility.
Findings
The inspection found that the central air conditioning units were broken in several areas, causing discomfort to residents with temperatures reaching up to 90 degrees Fahrenheit prior to the use of portable AC units. One deficiency was cited related to personal rights due to broken air conditioning units posing an immediate health, safety, or personal rights risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Broken air conditioning units in the common areas posing an immediate health, safety or personal rights risk to persons in care. | Type A |
Report Facts
Portable AC units purchased: 5
Box fans purchased: 3
Deficiencies cited: 1
Plan of Correction due date: Sep 10, 2022
Facility capacity: 197
Facility census: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Gardner | Licensing Program Analyst | Conducted the inspection and authored the report |
| Katherine Trevino | Administrator | Met with Licensing Program Analyst during inspection and discussed findings |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager and Supervisor |
Inspection Report
Original Licensing
Census: 92
Capacity: 197
Deficiencies: 0
Aug 3, 2022
Visit Reason
The inspection was a pre-licensing visit conducted due to a pending application for a change of ownership of the Residential Care Facility for the Elderly (RCFE).
Findings
The facility was found to be in compliance with all operational requirements, including fire clearance, safety postings, medication storage, food supplies, and resident unit conditions. No deficiencies were identified during the inspection.
Report Facts
Fire clearance date: Jul 12, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Kenny Espinal | Executive Director | Facility Executive Director present during inspection |
| Moises Bercovich | Licensee present during inspection |
Inspection Report
Original Licensing
Census: 91
Capacity: 197
Deficiencies: 0
Jul 26, 2022
Visit Reason
The visit was a pre-licensing inspection conducted via telephone call to complete Component II (COMP II) of the licensing process for the facility.
Findings
The applicant and administrator successfully completed COMP II, demonstrating understanding of Title 22 regulations including facility operation, staff qualifications, training, grievances, medication management, and application document review.
Report Facts
Capacity: 197
Census: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenny Espinal | Administrator | Named as facility administrator participating in COMP II |
| Adam Zenou | CEO/Owner | Named as CEO/Owner participating in COMP II |
| Shannon Betker | Analyst | CAB analyst conducting COMP II |
| Darla Neeley | Licensing Program Manager | Named as Licensing Program Manager on report |
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